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'Pq�,IN San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> \q<iF ORN/P <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 andq the Standards of San Joaquin County Environmental Health Department. <br /> L <br /> r�� Assessors Z 7 f1 <br /> WELL Location �rti. 44 a'K ./ Crdss Street City -7k1l r 4 Zip 1�? ){' Parcel# 5VZ <br /> PROPER /� �S�QLy <br /> Owner e4-G//SR. O1� Address Ck/I S'r*A /Q,1CJ City zipp Phon�e/�#���/7 <br /> C•57 Contrador�6Q/ CONSU//7/rn _Address 3�!/ (.l�<sf l- �Ii1y(.� 4.c zip1j��uc#J.Iptcxi Whone# 16-31/—! 9D <br /> Consultant/Sub Cntr C4 5A f-L Address Ciry Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> .SOIL BORING# I `L 0 OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT " <br /> a*Other GROUT SPECIFICATIONS� R L C/vr ae <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING X3IOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS Il MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL u PVC a OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS p HOSE o <br /> Q AIR SPARGE/OZONE o PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ' Yes 0 No NOTE: MAXIMUM FREE-FALL D PTH IS 30') O <br /> OIL BORING a HAND AUGER GROUT SPECIFICATIONS $ �� / �iAr i'l,ct1-- 1� ."J <br /> p OTHER:_U OTHER APPROX.BORING DEPTH S p BOLTED TRAFFIC BOX or a STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:T12&`'t/E 61eD6LZ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi rt s Rules and Regulations,and all applicable California State Laws/. � / <br /> Signed x ! Title/Company J '�00 e-4 A I"/�r C2 1G yJ <br /> Print Nam r LO Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: d�S 700 C(ftk-iS'^IqA) !`PG <br /> WORK PLAN DATED: <br /> Application Accepted By �✓` '� Date lssued I//Z/o/ Area <br /> Grout Inspection By r _Date�W11,97—Final Inspection By Date <br /> Destruction Inspection By D t2 e' <br /> COMMENTS/CONDITIONS: -'x ✓.lkr o .F n <br /> ACCOUNTING ONLY: AI FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* j REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> a� �l 6yV8( SR#06� " <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> E1D 29-02-001 <br /> 6122/D4 <br />